A comparison study of two breathing exercise techniques in tetraplegics

doi:10.4236/health.2009.12015

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Vol.1, No.2, 88-92 (2009)

doi:10.4236/health.2009.12015

Health

Openly accessible at

A comparison study of two breathing exercise

techniques in tetraplegics

Stanley John Winser1, Jacob George2, Priya Stanley1, George Tharion2

1Masterskill University of Health Science (MUCH), Cheras, Malaysia; [email protected], [email protected],

[email protected]

2Christian Medical College, Vellore, India.

Received 15 July 2009; revised 23 July 2009; accepted 25 July 2009.

ABSTRACT

Objective: To compare the effectiveness of ab-

dominal weights and incentive spirometry for

improving the strength of diaphragm in tetra-

plegics.

Setting: Department of Physical Medicine and

Rehabilitation, Christian Medical College, Vel-

lore, Tamil Nadu, India.

Study Design: Two group comparison study

Methods: Seventeen patients who fulfilled the

inclusion criteria were assigned into an ABW or

INS treatment groups using judgment sampling

after obtaining an informed consent. Evaluation

of the chest, respiratory status, vital signs and

strength of diaphragm were done during initial

assessment. ABW group underwent diaphrag-

matic strengthening using Abdominal weights

(ABW) and INT group with Incentive Spirometer

(INS) for 15 minutes daily, 6 days a week, for a

period of 6 weeks. The pre and post training

values of peak amplitude in electro myogram

(EMG) of the diaphragm, intercostals and ster-

nocleidomastoid muscles were measured.

Statistical analysis: The analysis was done

using SPSS 11. The pre and post-training values

of peak EMG amplitudes of the diaphragm, inter-

costals and sternocleidomastoid were com-

pared within the groups using Wilicoxon’s sign

test and between the two groups using Mann-

Whitney’s test.

Results: The peak EMG of diaphragm of ABW

group raised from 1.1289 to 1.3036 milli-volts

with a significance of p<0.001, whereas it fell

from 1.7001 to 1.0441 milli-volts among INS

group subjects with a significance of p<0.001.

Comparison between the 2 groups showed sta-

tistically significant improvement in diaphrag-

matic strength among the ABW group.

Conclusion: The results of this study sug-

gests that, in the pulmonary rehabilitation of

motor complete tetraplegic subjects abdominal

weighted training of the diaphragm has better

results in improving the strength of the muscle.

Sponsorship: Fluid research grant of Christian

Medical College, Vellore.

Keywords: Spinal Cord Injury; Tetraplegia;

Diaphragmatic Exercise; Surface EMG; Abdominal

Weights; Incentive Spirometer

1. INTRODUCTION

Spinal cord injury (SCI) at cervical level results in tetra-

plegia with or without paralysis of diaphragm. Among

complete tetraplegics with intercostals and diaphrag-

matic paralysis there is severe respiratory insufficiency

especially in the acute stage of illness [1]. Respiratory

insufficiency leads to high mortality rate in these pa-

tients [2]. Following cervical cord injury there is paraly-

sis of respiratory muscles [3] which leads to accumula-

tion of secretions. Failure of cough mechanism causes

recurrent infections which further compromises lung

functions and add to morbidity and mortality.

Studies on pulmonary function tests of individuals

with complete tetraplegia have shown that there is a ma-

jor loss of expiratory reserve volume due to paralysis of

expiratory muscles causing reduction of maximal expi-

ratory pressure. The work of breathing is increased and

the diaphragm is prone to fatigue particularly in patients

with high cervical cord lesion [4]. Physiotherapy man-

agement strategies aspire at improving efficiency of dia-

phragm and training the available accessory muscles to

compensate for paralyzed respiratory muscles. Progres-

sive resisted exercises have been used in strengthening

respiratory muscles for high tetraplegic patients [5].

There are various methods describe in literature to im-

prove the efficiency of diaphragm [6], which includes

Resisted Inspiratory Muscle Training (RIMT) [7,8,9],

Weighted diaphragmatic exercise [10], Abdominal bind-

ers [11], Trendlenbergs position and Incentive spirometry.

S. J. Winser et al. / HEALTH 1 (2009) 88-92

http://www.scirp.org/journal/HEALTH/

Openly accessible at

There is paucity of literature which compares the effec-

tiveness of abdominal weighted training and incentive

spirometry in improving the strength of diaphragm. This

study designed at evaluating the effectiveness of two

pulmonary rehabilitation programmes (weighted dia-

phragmatic exercise against incentive spirometry) which

are commonly practiced for training the diaphragm

among patients with spinal cord injury.

2. MATERIALS AND METHODS

This study was approved by the Institutional review

board and ethics Committee of Christian Medical Col-

lege. The background of the study was explained to the

subjects in his\her language and the patients who were

willing to participate were inducted into the study fol-

lowing an informed written consent. The sample size

was calculated to be 6 in each group with ABW group as

subjects trained with abdominal weights and INS group

as subjects trained with incentive spirometry. The sub-

jects with neurological level between C5 and C8 ASIA

[12] grade A & B, 1 month post injury, muscle strength

of diaphragm more than fair plus, medically stable pa-

tients and without any current lung infections or comor-

bidity were included in the study. Subjects with associ-

ated Traumatic Brain Injury (TBI), past history of

Chronic Obstructive Pulmonary Disease, Tuberculosis

and chronic smokers were excluded.

2.1. Sample Size & Method

The sample size was calculated with 5% alpha level and

80% power, with having a SD of 0.73 and 0.32; the

sample size was found to be 6 in each group. We had

adopted judgment sampling method. The subjects who

underwent weighted diaphragmatic training had to lie

supine. Since some subjects had pressure ulcer over the

sacral region, supine lying was contraindicated, which

made us to assign them into the INS group.

2.2. Evaluation of Strength [13]

The strength of diaphragm was graded using the grades

as follows. “Poor power”: is being graded if the subject

is not able to expand his\her epigastric region fully on

deep inspiration. “Fair power”: if the subject is able to

expand his\her epigastric region fully on deep inspiration.

“Good power”: the therapist’s hands are placed over the

epigastric region with fingers spread, and the subject is

asked to inhale, while maximum manual resistance is

applied. If the subject is able to complete a full epigas-

tric raise against resistance then he\she can be graded as

Good. The subjects who are able to take resistance but

not able to hold can be graded as “Fair plus”. Subjects

with diaphragmatic power of fair plus and above were

considered for progressive resisted exercises. Prior to the

commencement of training, the EMG activity of the

diaphragm, intercostals and sternocleidomastoid muscles

were evaluated.

2.3. Outcome Measure (EMG Analysis)

The EMG activity was measured using 3 pairs of Silver

chloride bipolar surface electrode. The active electrodes

were placed over T7 & T8 intercostal space, T4 & T5

intercostal space and mid portion of sternocleidomastoid

to get the electrical activity of diaphragm, intercostals

and sternocleidomastoid muscles respectively [14],

readings of all three groups of muscles were taken si-

multaneously (see Figure 1). Electrodes were secured to

the skin using adhesive plaster after skin preparation.

While taking the readings the subjects were instructed to

take 3 consecutive deep inspirations followed by expira-

tion, reading were recorded for 10 seconds and the peak

amplititudes in the EMG recordings noted. The investi-

gator who performed this test was blinded to either

group. Three trials were done and the best response of

peak amplitude was noted.

2.4. Intervention

The subjects were allotted into both groups using the

above mentioned sampling method. Subjects of both the

groups concurrently underwent other rehabilitative pro-

grams such as passive range of motion exercise, activi-

ties of daily living, standing using tilt or standing table,

strengthening or re-education for the available muscles.

In the ABW group, diaphragm was strengthened using

abdominal weights for 15 minutes per day for six days

weekly for a period of 6 weeks. The subjects of INS

group underwent training using incentive spirometer for

the same period as ABW group.

2.5. Evaluation of Weight [15]

To train the ABW group, the appropriate weights to

Figure 1. Showing placement of surface electrodes for the

assessment of EMG activity of Intercostals, Diaphragm and

Sternocliedomastoid muscles.

S. J. Winser et al. / HEALTH 1 (2009) 88-92

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Openly accessible at

strengthen the diaphragm were evaluated using the fol-

lowing method. The subject was positioned in supine

lying, then a minimal weight was placed over the epi-

gastric region (weights starts with half a kilogram) and

then the subject was allowed to breath (the weight

should come up fully with each inspiration). If the sub-

ject showed any signs of fatigue or started using his\her

accessory muscles, the weights were taken off immediately.

Adequate rest was given, then the procedure was re-

peated using a lesser weight, and if the patient is able to

take up the weight comfortably for 15 minutes, a short

break was given and the procedure was repeated by in-

creasing the weight by half a kilogram, thus the appro-

priate weight for training the diaphragm was determined

by trial and error method. Using the evaluated weight the

diaphragm was strengthened during the study period.

2.6. Placement of Weight

The evaluated weight was placed over the epigastric

region with an isosceles triangular board. The board is

placed in such a way that one of the corners touches the

xiphisternum and the other two corners touching the

anterior borders of the ribcage (see Figure 2). During

the training period of the ABW group, subjects were

instructed to perform normal breathing with the weights

on for 15 minutes and progression in weights was done

for every 1 week.

2.7. Incentive Spirometry Training

The INS group subjects were trained using an Incentive

spirometer, it is a flow oriented breathing exerciser. The

devise is provided with 3 balls and they provide the pa-

tients an indirect indicator of the inspired volume. Three

color-coded balls (3 shades of green) in each chamber

provide a visual incentive for the patient. Air flows into

single channel, when it passes through the chamber, it

raises each of the three balls depending on the flow in-

haled per second. Flow rates of the spirometer includes

600mL/sec, 900mL/sec and 1200mL/sec. By using dif-

ferent colors of ball it becomes easy to identify the flow

rate. Subjects of this group were instructed to keep the

balls of the spirometer suspended for maximum time

possible, this was repeated for 15 minutes daily for a

period of 6 weeks. Progression was made by increasing

the suspending time of the spirometer ball.

At the end of 6 weeks training, the EMG activities of

diaphragm, intercostals and the sternocleidomastoid

muscles were re-examined and compared for results.

3. STATISTICAL ANALYSIS

The analysis was done using SPSS 11. Baseline values

were tabulated as shown in Table 1.The pre and

post-training values of peak EMG amplitudes of the dia-

Figure 2. Diaphragmatic strengthening using abdominal

weights.

Table 1. Baseline characteristics of analysed data.

Characteristics Group (A) Group (B)

Mean age 36+/-12.32 27.16+/-8.91

Male 7 6

Sex Female - -

Traumatic 6 5

Cause of

lesion Non traumatic 1 1

Time since injury (days) 68+/-32.72 74.32+/-38.71

A 5 3

ASIA clas-

sification B 2 3

Presence of sacral ulcers - 5

phragm, intercostals and sternocleidomastoid were com-

pared within the groups using Wilicoxon’s sign test and

between the two groups using Mann-Whitney’s test.

4. RESULTS

Seventeen subjects were recruited into the study with 9

patients in group A and 8 in group B. Thirteen subjects

had completed the study and were available for the post

training assessment and analysis. Two subjects from

each group dropped out from the study. Among 4 sub-

jects dropped out, two were not willing to undergo post

training assessment, one subject got discharged against

medical advice and another subject was shifted to critical

care unit. The mean age of subjects was 35 years (range

19 to 53 years).

Among 17 subjects, 13 had traumatic SCI and re-

maining 4 patients had infective pathology of the cord.

Mean duration since injury was 71.61 days (range 32 to

142). There was a significant increase in the diaphrag-

matic activity of subjects in the ABW group, shown in

Table 2, whereas there was a significant reduction in the

EMG activity among the INS group, shown in Table 3.

Comparison between the 2 groups using Mann-Whit

S. J. Winser et al. / HEALTH 1 (2009) 88-92

Table 2. Change in EMG ( milli volts) within ABW group.

Pre- test Post – test

Group

A Mean SD Mean SD P Z

T4 0.8478 0.8463 1.2915 1.5638 <0.001 -23.490

T5 0.7253 0.7974 1.2366 1.4240 <0.001 -31.986

T7 1.1289 0.7862 1.3036 1.2129 <0.001 -6.273

T8 0.8188 0.6440 0.8977 0.9190 <0.001 -0.475

SCM 1.5027 1.8742 1.2527 1.5241 <0.001 -8.424

Table 3. Change in EMG ( milli volts) within INS group.

Pre- test Post – test

Group

B Mean SD Mean SD

P Z

T4 0.95540.89230.7368 0.7668 <0.001-17.659

T5 1.17561.00810.9361 0.8993 <0.001-14.078

T7 1.70011.41440.9631 0.8993 <0.001-31.584

T8 1.81941.83670.9823 0.9823 <0.001-25.335

SCM 2.39852.43652.0446 1.8431 <0.001-9.838

Table 4. Comparing change in EMG (milli volts) between the 2 groups.

Group (A) Group (B) P Z

Muscle

Pre Post

Pre Post Pre post

T4 0.8472 1.2915 0.00 0.9554 0.7368 <0.001 -14.019 -19.676

T5 0.7253 1.2366 0.00 1.1756 0.9631 <0.001 -40.670 -0.105

T7 1.1289 1.3036 0.00 1.7001 1.0441 <0.001 -23.396 -8.030

T8 0.8188 0.8977 0.00 1.8194 0.9823 <0.001 -32.875 -13.278

SCM 1.5027 1.2524 0.00 2.3985 2.0446 <0.001 -20.671 -27.735

ney’s test showed a statistical significance (p<0.001) in

the improvement of diaphragmatic activity in ABW

group, shown in Table 4. The mean EMG of diaphragm

of ABW group raised from 1.1289 to 1.3036 milli-volts

with a significance of p<0.001, whereas it fell from

1.7001 to 1.0441 milli-volts among INS group subjects

with a significance of p<0.001. When comparing the

EMG activities of both the groups a statistically signifi-

cant improvement in diaphragmatic strength was ob-

served among the ABW group.

5. DISCUSSION

The objective of the study was to determine which of the

two techniques, (abdominal weights or incentive spi-

rometry) improves the strength of diaphragm among

complete tetraplegic patients. Results of this study have

shown that patients trained with weighted diaphragmatic

exercise had better improvement in the post training as-

sessment of EMG values. Pulmonary rehabilitation ex-

ercise protocols prescribed for the spinal cord injured

patients with reduced pulmonary function is very effec-

tive to provide a positive outcome. Pulmonary exercises

are simple and effective without any need to procure

sophisticated instruments. Studies done on the progres-

sive resistive exercises for the respiratory muscles have

proved that this method of diaphragm training may be

useful in weaning high level quadriplegic patients from

the ventilator.

Studies on pulmonary function tests of individuals

with complete tetraplegia showed that there is a major

loss of expiratory reserve volume because of paralysis of

expiratory muscles, as a result of which their maximal

expiratory pressure was reduced. The vital capacity ap-

proximates their inspiratory capacity. The work of

breathing is increased and the diaphragm is prone to

fatigue particularly in patients with high cervical cord

lesion [16].

Carolyn Kisner and Lynn Allen Colby in their discus-

sion on various techniques used to strengthen diaphragm

suggested; incentive spirometry is a form of low level

resistance training that emphasizes sustained maximal

inspiration. The training sessions of the above mentioned

studies were typically limited to 15 to 30 minutes each,

with two to three sessions a day, 5 to 7 days a week for a

total period of 6 to 8 weeks.

Previous studies have compared the effectiveness of

resistive inspiratory muscle training (RIMT) and ab-

dominal weights in improving the strength of diaphragm

among tetraplegic patients and have proved that both the

techniques are equally effective [17]. Hwa Lin and Chy

Ching Chuang observed that Abdominal weighted

maximal ventilatory (AWMV) breathing evoked greater

EMG activity, inspiratory flow and inspiratory volume

than did (Inspiratory resistance maximal ventilatory

(IRMV) breathing. The increase of diaphragmatic EMG

was not statistically significant in AWMV breathing.

Weighted diaphragmatic strengthening is a less com-

monly employed strengthening program. Studies had

shown that the use of weighted diaphragmatic exercise

was of great therapeutic use, and have compared the

effects of abdominal weights against resistive inspiration

as mentioned before. On the other hand in recent days

incentive spirometry is the most commonly administered

S. J. Winser et al. / HEALTH 1 (2009) 88-92

http://www.scirp.org/journal/HEALTH/

Openly accessible at

treatment regimen in improving the strength and effi-

ciency of diaphragm among tetraplegics. In our study we

have observed, the most efficient and cost effective mo-

dality in the pulmonary management of tetraplegic pa-

tients is abdominal weighted exercise.

We hypothesized a reduction in the EMG activity of

the sternocleidomastoid muscle following training due to

an improvement in the efficiency of diaphragm which is

the primary respiratory muscle. We found an increase in

the activity of sternocleidomastoid muscle among ABW

group subjects along with the increase in activity of the

other groups of muscles (intercostals and diaphragm).

There was a reduction in activity of sternocleidomastoid

muscle among the INS group subjects. However we

could not explain the reason for this phenomenon. The

results of this study are not concurrent with the previous

literature; instead has proved that resistive diaphragmatic

breathing exercise has better therapeutic effects in im-

proving the strength of diaphragm among complete

tetraplegic patients.

There were few limitations in our study which in-

cludes the sampling technique and spasticity of the sub-

jects. There are possibilities that disturbances from the

abnormally activated trunk muscles could have reduced

the accuracy of EMG activity of the diaphragm and

other respiratory muscles. The sampling method had to

be judgement sampling rather than single blinded simple

random sampling which could have been ideal for this

study.

6. CONCLUSIONS

The peak EMG amplitude showed a significant rise

amongst subjects who were trained using abdominal

weights. This is an apparent indication of improved per-

formance of the target muscle with regards to strength.

Cost effectiveness and ease of administration of this

technique ensures its frequent usage by clinical practi-

tioners. Thus we conclude stating Abdominal weights

can be used as an effective adjunct to pulmonary reha-

bilitation in improving the strength of diaphragm,

thereby reducing the risks associated with pulmonary

complications.

7. ACKNOWLEDGEMENT

We gratefully acknowledge Mr. Ganesh, Movement Analyst who as-

sisted us in collecting EMG recordings for all our patients and Mr.

Vijayakumar for his guidance. We also acknowledge the Fluid research

committee for funding our project.

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